Registration Form and Medical History

Your answers will help us to find the necessary homeopathic-miasmatic remedies for the initial healing step and to gain a better understanding of the root of your illness. If there is not enough space in this form for your answers please feel free to send any additional information/comments via email. Please fill in and send the completed medical history form as soon as possible before your first consultation so that I can be well prepared and informed about your medical history before our first appointment. Thank you!

Name:
Address:
Postcode:
Tel.:
Mobile:
Email address:
Date of birth (DD/MM/YY):
Profession:
Health insurance:
What motivated you to come to me?
In which body part do you experience your illness?
What is the clinical diagnosis?
Please explain in a few words the nature of your problem?
When did the feeling of illness start?
Please try to remember if anything drastic/serious happened in your life in the preceding 1-2 years
Your medical history:
Have you suffered from a bladder infection?
If so how often?
Yes  No
often  once
Have you suffered from chicken pox   mumps   diphtheria
scarlet fever   rubella
When you were a child did you suffer from: swollen glands   alopecia
scuffy eczema
Have you suffered from: ulcers   boils   fistulas
abscesses
If yes, where on your body?
Have you ever suffered from: eyes clotted by secretion in the morning
fishy smelling vaginal discharge
unilateral knee pain
What have you (often) suffered from: problems with gallbladder   depression
joint problems   hair loss
unilateral headache   bilateral headache
teeth problems   heart problems
thyroid problems   broken bones
vein stasis/varicose veins
vaginal discharge white   gelb   greenish
brown   with fish odour
divided urinary stream   twisted urinary stream
accidents   forgetfulness
mystical experiences   fits of rage
listlessness   impotence
allergies   skin problems
Which allergies or skin problems?
Do you sweat easily?Yes  No
Do you use a deodorant?Yes  No
Do you get feverish easily? Yes  No  Not at all
Have you taken antibiotcs?often  sometimes  rarely
Have you taken fever reducing drugs?often  rarely
Have you treated eczema / spots with chemical substances?Yes  No
Have you taken headache tablets?often  occasionally
Have you taken antidepressants/psychotropic drugs?often  rarely
Have you suffered from athletes foot / nail fungus?
have you used chemical substances for treatment?
Yes  No
Yes  No
Have you been vaccinated often?When you were a child  as an adult
When was your most recent vaccination? Which kind?
Do you have the feeling that you have experienced a trauma?
Have you ever lost your job?
If so, when?
Yes No
Have you ever suffered from existential fears?Yes  No
Have you experienced bullying at work?Yes  No
Have you had to work for a younger, less experienced boss?Yes  No
Have you been forced into early retirement?Yes  No
Are you retired?Yes  No
Have you been told that slowly but surely you might be too old for your job?Yes  No
Have you ever had the feeling of being superfluous?Yes  No
Have you ever had the feeling of having no prospects / future anymore?Yes  No
Have you ever had the feeling of fighting a losing battle?Yes  No
Have you been in a position where you suffered from fear of death?Yes  No
Have you experienced a near death experience?Yes  No
Has your sense of smell been disturbed?Yes  No
Has your sense of taste been disturbed?Yes  No
Have you suffered from hearing problems?
Where?
Yes  No
left  right  both sides
Have you ever experienced numbness?
Where?
Yes  No
of your skin  of the fingers
of the legs  of the feet
Anywhere else?
Are you in a relationship with a woman/man?
If so, is your relationship...?
Yes  No
fulfilling  not fulfilling  problematic
Do you prefer to live alone?Yes  No
Have you had / Do you have relationship problems?Yes  No
Are you in a gay same-sex relationship?Yes  No
Are you in a lesbian same-sex relationship?Yes  No
Have you ever been left by your partner for someone else? Yes  No
Do you have feelings of guilt?Yes  No
Have you ever had the feeling of carrying a burden for somebody elseYes  No
Have you had the feeling that something sticks to you?Yes  No
Have you ever experienced hardshipYes  No
Do you have the impression that there was hardship in your family?Yes  No
Have your parents worked their way out of poverty?Yes  No
Have you worked your way out of poverty?Yes  No
Are you hard-working?Yes  No
Do you have a tendency to overwork without giving yourself breaks?Yes  No
Do you have a tendency to always feel responsible for others?Yes  No
Your Family Constellation:
Mother alive?
If not, mother died in?
Yes  No
from?
Mother's diseases?
Have you been your mother's carer?
If so for how long?
Yes  No
Your relationship to your mother is/was?close  not good  difficult
Were you breastfed by your mother?Yes  No
Were you a wanted baby?Yes  No
Did you have the sex your parents hoped for?boy  girl
Were you born out of wedlock?Yes  No
Your birth was?normal  difficult  caesarean
precipitate labour  breech delivery  home birth
in a labour ward  in a refugee camp
Were you separeted from your mother when you were a child?Yes   often  No
Is/was your mother?sensitive  artistic   introverted
weak
Was/is she:working  rarely at home  choleric  unjust  loud  dominant  an alcoholic
did she put your father down
Did she beat you?Yes  did she beat your father?
did she beat your siblings?
Were you her favourite daughter/son?Yes  No
Father alive
If not, father died in?
Yes  No
from?
Father's diseases?
Have you been your father's carer?
if so for how long?
YesNo
Your relationship to your father is/was?clos  not good  difficult
Your parents...live(d) together  were/are seperated
were/are divorced
Was/is your father:sensitive  sensitive  introverted
weak  rarely at home  choleric
unjust  loud  an alcoholic
Did he beat you?Yes  Did he beat your mother?
Did he beat your siblings?
Were you his favourite daughter/son?Yes  No
Have your sibblings suffered from diseases?
Your grandparent's diseases
Your grandmother on your mother's side
died of?
when?

Your grandfather on your mother's side
died of?
when?

Your grandmother on your father's side
died of?
when?

Your grandfather on your father's side
died of?
when?

Which diseases are you aware of on your mother's side?
Which diseases are you aware of on your father's side?
Have any of the following occured in your wider family?tuberculosis  gonorrhoea  syphilis  malaria
any tropical disease  helminthic/worm diseases
psoriasis  diabetes  rheumatism
drug consumption  alcoholism
suicide  psychiatric diseases
abuse  murder  
Have you identified certain „patterns“ within your family (behaviour, frequent events like accidents, death at a young age, similar diseases etc.)?
 
Declaration of Informed Consent

Dear patient,

We are glad, that you have chosen a naturopathic therapy. Naturopathic therapies are known as relatively safe treatment methods because of the thousands of years application and experience. Illnesses represent a disorder in the human functional processes on an organic and psychical level. That is why every treatment requires an individual treatment concept. Diagnosis and therapy are carried out on a holistic level. It means that not only the physical complaints or pains are treated, but the causes of the diseases are to be traced. The therapy methods work on the basis of the naturopathic principle. A balance is to be reached due to the stimulation of the patient's self- healing power. In this way the therapies are considered to be riskless.

For the purposes of inszrance, I would like to refer to some possible side effects. Acupuncture can lead to hemorrhages and organ injuries. Chinese herbs can cause diarrhoea or vomiting. When using moxibustation burns are possible. When injecting soft parts and nerves can get injured, haematomas and abscesses can occur. Infusion therapy can lead to allergic itching and shock. Chirotherapeutic treatments can tear arteries and activate asymptomatic herniated discs. Oxygen therapy can aggravate an existing inflammation. Hypnosis and relaxation exercises can cause a short term concentration disorder. Without a clear oral or written disclaimer I avow myself to agree with the treatment to be done.

The prices are calculated on the basis of the price list hanging in the waiting room. The price of the treatments are not covered by the compulsory health insurance funds. The naturopath is not responsible for refunds by private health insurance companies, extra health insurances or financial support. The treatment costs are to be paid upon receipt of the bill directly and without delay independent from the payment of the insurance companies. Appointments must be cancelled 24 hours in advance if necessary (an appointment on Monday must be cancelled on Friday), otherwise missed appointments will be charged in full. I hereby declare that I have read and understood the informed consent in detail and all my questions in connection with it have been clarified. I agree with the settlement mode.

I have read and accepted the above Declaration of Informed Consent:  


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